[Federal Register Volume 74, Number 242 (Friday, December 18, 2009)]
[Notices]
[Pages 67232-67234]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-29724]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2311-NC]


Medicaid Program and Children's Health Insurance Program; Model 
of Interstate Coordinated Enrollment and Coverage Process for Low-
Income Children

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice with comment.

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SUMMARY: This notice requests comments to assist in the development of 
a model process for the coordination of enrollment, retention, and 
coverage for low-income Medicaid and Children's Health Insurance 
Program eligible children as required under the Children's Health 
Insurance Program Reauthorization Act (CHIPRA) of 2009. CHIPRA requires 
this model process to be developed by August 4, 2010 and the Secretary 
is required to submit a Report to Congress describing additional steps 
or authority needed to make further improvements to coordinate the 
enrollment, retention, and coverage under CHIP and Medicaid of low-
income children who frequently change their State of residence.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on January 19, 2010.

ADDRESSES: In commenting, please refer to file code CMS-2311-NC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the instructions under 
the ``More Search Options'' tab.

[[Page 67233]]

    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-2311-NC, P.O. Box 8010, 
Baltimore, MD 21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-2311-NC, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Wanda Pigatt-Canty, (410) 786-6177. 
Mary Corddry, (410) 786-6618.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments 
received before the close of the comment period are available for 
viewing by the public, including any personally identifiable or 
confidential business information that is included in a comment. We 
post all comments received before the close of the comment period on 
the following Web site as soon as possible after they have been 
received: http://www.regulations.gov. Follow the search instructions on 
that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

    Section 213 ``Model of Interstate Coordinated Enrollment and 
Coverage Process'' of the Children's Health Insurance Program 
Reauthorization Act (CHIPRA) of 2009 requires the Secretary of Health 
and Human Services (HHS), in consultation with State Medicaid and 
Children's Health Insurance Program (CHIP) directors and organizations 
representing program beneficiaries, to develop a model process by 
August 4, 2010, that assures the continuity of coverage for low-income 
children under Medicaid and CHIP. The model process will be designed 
for the coordination of enrollment, retention, and coverage for 
children under the Medicaid and CHIP programs, who, because of 
migration of families, emergency evacuations, natural, or other 
disasters, public health emergencies, educational needs, or otherwise, 
frequently change their State of residence or are temporarily located 
outside their State of residence. American Indian and Alaska Native 
children who need care while attending boarding schools or need 
culturally appropriate care available only in a State where they do not 
reside are a key example of this population.
    CHIPRA requires the Secretary, after developing a model process, to 
submit a Report to Congress that would describe additional steps or 
authority needed to make further improvements to coordinate the 
enrollment, retention, and coverage under CHIP and Medicaid of low-
income children who frequently change their State of residence or are 
temporarily located outside their State of residence.

A. CMS Historical Experience Related to Continuity of Coverage

    In 2006, CMS prepared a Report to Congress as required by section 
404 of the Health Care Safety Net Amendments Act of 2002 (Pub. L. 107-
251) entitled ``Study Regarding Barriers to Participation of Farm 
Workers in Health Programs.'' This report highlighted problems 
experienced by migrant farmworkers and their families related to the 
barriers encountered in accessing health services through Medicaid and 
CHIP, and the lack of portability of Medicaid and CHIP coverage for 
farmworkers who are determined eligible in one State but who, due to 
the seasonal nature of the their work, periodically move to other 
States. We published the outcome of this study in a Report to Congress 
which identified five options to address the portability issues related 
to Medicaid and CHIP. The recommended options included the following:
     Interstate Compacts.
     Demonstration Projects.
     State Activities under Current Law Flexibility.
     National Migrant Family Coverage.
     Public-Private Partnerships.
    The full Migrant Farmworkers Report to Congress can be viewed at: 
http://cms.hhs.gov/Reports/Downloads/RTC-Leavitt2.pdf.

B. Proposed Models for Coordination

    We are using some of the recommendations from the Migrant 
Farmworkers Report to Congress as the basis for proposing models of 
coordination/portability to attempt to solve the problem of gaps in 
healthcare coverage for Medicaid and CHIP children who frequently 
change their State of residence. We have identified four proposed 
models including a new model titled ``National Children's Health 
Coverage Option'' on which we are seeking input. These models include:
    (1) Interstate Compacts. Under current Federal law and regulations, 
States may enter interstate agreements to facilitate administration of 
their Medicaid and CHIP programs. Interstate compacts are agreements 
between States that provide the framework for formalized interstate 
cooperation. The framework ranges from a more basic model in which 
States recognize each other's eligibility determinations to models with 
States fully reimbursing out-of-state providers. States may seek to 
develop interstate agreements or compacts to facilitate timely 
eligibility determinations or redeterminations for applicants and 
recipients, such as migrant farmworkers, and agree upon detailed 
mechanisms by which payment reciprocity can be made among two or more 
States. These interstate arrangements, however, do not necessarily 
require Federal approval. By establishing and joining an

[[Page 67234]]

interstate compact on Medicaid and CHIP for children, States can more 
readily recognize each other's eligibility determinations and reimburse 
out-of-state providers. As a result, they can provide more seamless 
Medicaid and CHIP coverage to low-income children. States currently 
participate in a variety of interstate compacts including one 
pertaining to Federal adoption assistance/Medicaid recipients entitled 
the ``Interstate Compact on Adoption and Medical Assistance'' (ICAMA). 
Further information related to ICAMA can be viewed at: http://www.aaicama.org/cms/.
    (2) Demonstration Projects. Section 1115(a) of the Social Security 
Act (the Act) provides the Secretary of Health and Human Services with 
the authority to authorize experimental, pilot, or demonstration 
projects which, in the judgment of the Secretary, are likely to assist 
in promoting the objectives of the Medicaid statute. States can request 
section 1115 authority to create a standard set of benefits or 
eligibility coverage across States that differ from the set of benefits 
provided under the State plan in each of those States or to expand 
coverage to groups of individuals, including parents and caretaker 
relatives, or to provide greater flexibility in their programs. Budget 
neutrality is required for title XIX programs approved under section 
1115 authority under the policies of the Office of Management and 
Budget. A recent example of how CMS used section 1115 authority was in 
2005, in response to the devastation caused by Hurricane Katrina on the 
health care system of the Gulf coast of Louisiana and Mississippi; the 
Secretary was granted the authority to approve section 1115 
demonstration waivers that granted States time-limited waiver authority 
to facilitate expedited enrollment into Medicaid and CHIP programs for 
survivors of Hurricane Katrina who needed to access healthcare services 
in locations other than their home States. Under Hurricane Katrina 
demonstrations, we granted time-limited waiver authorities to States 
for the following:
     Simplified eligibility criteria for Medicaid and CHIP 
eligible groups.
     Comparability/amount, duration, and scope of benefit 
packages.
     Simplified eligibility determination processes in order to 
permit evacuees to access needed health care services in their host 
State.
    (3) State Activities under Current Law's Flexibility. States may 
explore current flexibility under State plan authority to improve the 
continuity of coverage for Medicaid and CHIP eligible children. Some of 
the flexibility offered under the State plan authority may be designed 
to improve service delivery coordination; enhance enrollment and 
portability arrangements; and enhance Medicaid and CHIP managed care 
coordination at the State and health plan levels to facilitate 
enrollment and portability. Under this model for example, a State may 
choose to align/standardize their eligibility and enrollment processes 
with a neighboring State in order to improve coordination of Medicaid 
and CHIP coverage for children.
    (4) Public-Private Partnerships. States may engage in public-
private partnerships in order to research or pilot initiatives that 
improve the portability of Medicaid and CHIP coverage for low-income 
children.
    (5) National Children's Health Coverage Option. This model would 
develop a national health insurance plan for children with a minimum 
benefit plan to be offered by every State. Under this option, certain 
statutory changes would be required related to the definition of 
residency and eligibility criteria for children, specifically a minimum 
national coverage for all children under age 21 years and a change in 
the income standard to a specified minimum level for all children. 
State residency could be defined to make it easier to cover children in 
the State where they are living, even if they do not intend to remain 
there permanently or for an indefinite period.

C. Request for Comments

    We request public comments on the proposed models to include the 
following:
    (1) Advantages (benefits) and/or disadvantages (negatives) related 
to each of the proposed models.
    (2) Best practices States may currently have in place to ensure 
interstate continuity and coordination of enrollment for Medicaid and 
CHIP children.
    (3) Recommendations for new models that will facilitate 
coordination of enrollment, retention, and coverage for Medicaid and 
CHIP children.
    (4) Additional comments related to programmatic operations and/or 
statutory changes that may be required in order to create the model 
process.

D. Use of Public Comments

    We will review the public comments and consider the information 
received in the development of the model process for the coordination 
of enrollment, retention, and coverage for Medicaid and CHIP children 
who frequently move from their State of residence.

II. Provisions of the Notice With Comment

    The purpose of this notice is to provide the opportunity for public 
input/consultation in developing a model process for the coordination 
of enrollment, retention and coverage for Medicaid and CHIP eligible 
children who, because of migration of families, emergency evacuations, 
natural or other disasters, public health emergencies, educational 
needs, or otherwise, frequently change their State of residency or 
otherwise are temporarily located outside the State of their residency.

III. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble, 
and, when we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.
    In accordance with the provisions of Executive Order 12866, this 
notice was not reviewed by the Office of Management and Budget.

    Authority:  Section 1115 of the Social Security Act.

(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: November 2, 2009.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. E9-29724 Filed 12-17-09; 8:45 am]
BILLING CODE 4120-01-P